Provider Demographics
NPI:1013768605
Name:PALLUCONI, MICHAEL ANDREW
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:ANDREW
Last Name:PALLUCONI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 COYOTE RUN
Mailing Address - Street 2:
Mailing Address - City:SPENCERPORT
Mailing Address - State:NY
Mailing Address - Zip Code:14559-2609
Mailing Address - Country:US
Mailing Address - Phone:585-694-6611
Mailing Address - Fax:
Practice Address - Street 1:625 ELMWOOD AVE # 683
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14620-2913
Practice Address - Country:US
Practice Address - Phone:585-275-5051
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-01
Last Update Date:2024-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program